Consent to Evaluate and Treat a Minor

Consent to Evaluate and Treat a Minor

www.boundlesshope.net - 813.219.8844
I client's parent name*, as the parent/legal guardian ofminor's legal name*. DOB Date* consent for the evaluation and treatment of this minor and I hereby certify that I have the legal right to seek counseling treatment for minor(s) in my custody and give permission to Therapist's name* to provide treatment to my minor child(ren).
If I have unilateral decision-making capacity to obtain counseling services for my minor, I

will provide the appropriate court documentation to Therapist's Name* prior to or at the initial session.
Consent for the evaluation and treatment of this minor.

By voluntarily signing below, I understand that my child, although a minor, is legally and ethically given total confidentiality with the exception being those circumstances discussed on consent to treatment form which are danger to self, danger to others, or being endangered by others.
Parent/Legal Guardian Signature*

Clear
Relation To Minor*
Date*

MonthDayYear
Date
If treatment is for a non driving minor, it is REQUIRED that the designated responsible adult, remain on site at Boundless Hope for the duration of treatment. If I permit anther adult to transport my child, their name and relationship to minor is listed below.
Transportation to and from given to: (Name and relationship to minor)*
Decision Making/ Parenting Order Upload*

Cancelof
Email for a copy of form to your inbox!*
example@example.com
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